Surgical Respiratory Diseases

Question 1

What are the features of Brachycephalic Obstructive Airway Syndrome (BOAS)?

Answer 1

Stenotic nares
Overlong soft palate
Enlarged tonsils
Everted laryngeal saccules
Hypoplastic trachea
Hiatal hernia
Stertor / Stridor
\+/- laryngeal collapse

Question 2

Describe narrow nares in BOAS.

Answer 2

Dramatically increase resistance to air flow into the nose

Cartilage supports of the nares tend to collapse during inspiration, requiring even more effort to breathe

Question 3

Describe laryngeal collapse in BOAS.

Answer 3

Progressive collapse of the larynx
Graded in terms of severity from 1 (least severe) to 3 (most severe)
Rate of progression may be able to be slowed with appropriate treatment

Question 4

Describe an overlong soft palate in BOAS.

Answer 4

Can partially obstruct air flow into the trachea and cause turbulent airflow in the area of the larynx

Question 5

What nursing/owner considerations should we have for BOAS patients?

Answer 5

Avoid stress/heat
Use harness, not collars
Achieve/maintain ideal bodyweight
Carefully managed exercise regimes
Oxygen therapy
Owner education (signs of respiratory distress)

Question 6

What should we assess pre-operatively in BOAS patients?

Answer 6

TPR
MMs and CRT
SpO2
Clinical signs of BOAS/assessment with vet - ASA grading

Question 7

What surgical options do we have to treat BOAS?

Answer 7

Soft palate resection (staphylectomy)
Tonsil resection
Removal of everted laryngeal saccules
Nostril resection (correct stenotic nares)
Laster assisted turbinectomy (LATE)
(May be performed together as multilevel surgical correction)

Question 8

How do we prepare pre-BOAS surgery?

Answer 8

Full discussion with vet (ASA grading)
Informed consent - high risk surgery
Full analysis of biochem/haem
Pre-oxygenate for at least 5 mins - delays O2 desaturation at induction
Minimal stress via handling (IV catheter after premed if needed)
Peri-operatively - ocular lubrication + intensive monitoring

Question 9

How do we prepare for BOAS surgery?

Answer 9

Ensure all equipment prepared (lighting, laryngoscope, rescue ET tube)
Thoracic radiography
Minimal - no hair clip/scrub
Positioning - sternal, head raised using drip stands
Be ready for regurgitation - tilted table/suction

Question 10

What monitoring should be carried out peri-operatively?

Answer 10

O2 saturation (>98%)
Capnography - ETCO2 (35-45mmHg)
Use IPPV/mechanical ventilator as appropriate (consider circuit selection)
Blood pressure - mean > 60 mmHg (consider bolus IVFT if indicated)
Ocular lubricant frequently applied

Question 11

What complications can occur post-BOAS surgery?

Answer 11

Airway swelling
Vomiting and regurgitation
Aspiration pneumonia

Question 12

How do we recover BOAS patients post-op?

Answer 12

Extubation later than usual
Monitor O2 saturation
O2 supplementation post-extubation (mask/flow-by)
Sternal recumbency, head elevated
Suction available
Intensive monitoring charts - constant supervision

Question 13

How should BOAS patients post-op be managed at home?

Answer 13

Harness
Restricted exercise 5-10 mins twice daily - 6 weeks
Examination 2 and 10 days post-op
Wet solid food 6 weeks post-op - limit airway irritation

Question 14

What are the causes of laryngeal paralysis?

Answer 14

Ageing changes (degenerative neuropathy) - idiopathic
Congenital disease
Trauma (bite wounds, neck surgery)
Cancerous infiltration of nerve that controls the muscle

Question 15

What are the signs of laryngeal paralysis?

Answer 15

Exercise intolerance
Noisy respiration
Coughing, gagging
Change/loss of vocal sounds (dysphonia)
Dysphagia
Cyanosis and collapse - if severe

Question 16

How do we manage mild cases of laryngeal paralysis?

Answer 16

Anti-inflammatories
Antibiotics - where indicated
Sedative
Raised feeding
Reduce stress and manage exercise

Question 17

How do we manage severe cases of laryngeal paralysis?

Answer 17

Unilateral arytenoid lateralisation (laryngeal tie-back)
-Diagnosis under light plane of anaesthesia
-Surgery performed on left side of neck
Left arytenoid cartilage permanently tied open

Question 18

How do we care for laryngeal paralysis patients post-op?

Answer 18

Small, regular soft meals
Avoid dusty food/atmospheres
Raised feeding/water
Wound management

Question 19

What should we tell owners post-unilateral arytenoid lateralisation surgery?

Answer 19

Discuss permanent change in phonation
No swimming (risk of aspiration too great)
Prognosis positive unless systemic neuromuscular disorder

Question 20

What are the two types of palate defects?

Answer 20

Congenital, e.g. clefts of upper lip, hard and/or soft palate (clinical signs = difficulty feeding and nasal discharge)
Acquired, e.g. trauma, RTAs

Question 21

How do we treat congenital palate defects?

Answer 21

Surgery performed at 3-4 months
Closure of tissues separating the oral and nasal passages with minimal tension
Haemorrhage not uncommon

Question 22

How do we treat acquired palate defects?

Answer 22

Primary (surgery) or secondary (healing) closure.

Question 23

What surgical options do we have for tracheal collapse patients?

Answer 23

Extraluminal ring prosthesis

Intraluminal stent

Question 24

Describe an extraluminal ring prosthesis.

Answer 24

Invasive - risk management
Complications = vascular damage, tracheal ring migration, coughing, dyspnoea, laryngeal paralysis (due to iatrogenic nerve damage)

Question 25

Describe an intraluminal stent.

Answer 25

Less invasive surgery than extraluminal ring prosthesis
Durable material but can fatigue under pressure (e.g. repeated coughing)
Complication = excessive inflammatory tissue around trachea
Vital to control coughing post-surgery

Question 26

How do we prep a patient for extraluminal ring prosthesis surgery?

Answer 26

Surgical preparation (aseptic)
Ventral neck - large area
Dorsal recumbency
Discuss complications
Pre-oxygenation
Careful handling
Calm/stress-free

Question 27

How do we prep a patient for intraluminal stent placement?

Answer 27

Lateral recumbency
Fluoroscopic guidance
Pre-oxygenation
Careful handling
Calm/stress-free

Question 28

Describe a lateral thoracotomy.

Answer 28

Surgical incision performed between the ribs
Provides excellent view of one side of the thorax
Indications = lung lobectomy (abscessation/lung lobe torsion/neoplasia)

Question 29

Describe a median sternotomy.

Answer 29

Surgical incision through sternum
Provides view of bilateral thorax
Indications = pyothorax/mediastinal masses/heart surgery

Question 30

What are the indications for an emergency tracheostomy?

Answer 30

Facilitate anaesthesia when airway is compromised
Stabilise patient and allow airway management
Provide definitive airway until swelling/obstruction is resolved
Laryngeal paralysis/BOAS/foreign body/laryngeal trauma

Question 31

How do we care for a tracheostomy tube?

Answer 31

24/7 monitoring - maintenance, comfort, asepsis
Prevent build-up of secretion - suctioning, regular cleaning/changing tube
Initially every 15 mins, once stable every 4-5hrs

Question 32

What should we be continually checking for in patients with a tracheostomy tube?

Answer 32

Harsh respiratory sounds
Dyspnoea
Distress
Coughing
Discharge
Discomfort
Stoma - pain, swelling, heat

Question 33

How do we suction a tracheostomy tube?

Answer 33

Pre-oxygenate for min 5 mins
Aseptic technique
Sterile long, soft catheter - pre-measured no longer than top of trach tube
Once catheter in place, turn on suction unit
Move catheter in circular motion as withdrawing (15 secs)

Question 34

Why and how do we humidify tracheostomy tubes?

Answer 34

Bypassing normal humidification in URT
Drying can cause damage to mucosa (inflammation, irritation, thick mucus)
Humidification filters if available, attached to tube
0.5-3mls sterile isotonic saline - discussion with vet
Nebulisation - sterile saline 10mins every 2-3hrs